Review of Consumer Assessment to Manage PCA Services 

Introduction 

The Personal Care Management (PCM) agency should use this form to review the 
consumer’s ability to manage Personal Care Attendant (PCA) services at the time 
of reevaluation and before the prior authorization for PCA services expires. 
This form should be attached to the Consumer Assessment to Manage PCA Services. 

1st Review 

Date of Review Date of most recent Consumer Assessment to Manage PCA Services 

Name and Title of Assessor 

Check One: 

I have reviewed the most recent Consumer Assessment to Manage PCA Services and 
there have been no changes. 

I have reviewed the Consumer Assessment to Manage PCA Services and there have 
been changes that impact the consumer’s ability to manage the PCA program. (If 
this box is checked, conduct a complete Consumer Assessment to Manage PCA 
Services.) 

2nd Review

Date of Review Date of most recent Consumer Assessment to Manage PCA Services

Name and Title of Assessor

Check One:

I have reviewed the most recent Consumer Assessment to Manage PCA Services and 
there have been no changes.

I have reviewed the Consumer Assessment to Manage PCA Services and there have 
been changes that impact the consumer’s ability to manage the PCA program.  (If 
this box is checked, conduct a complete Consumer Assessment to Manage PCA 
Services.)

3rd Review

Date of Review Date of most recent Consumer Assessment to Manage PCA Services

Name and Title of Assessor

Check One:  
  
I have reviewed the most recent Consumer Assessment to Manage PCA Services and 
there have been no changes.

I have reviewed the Consumer Assessment to Manage PCA Services and there have 
been changes that impact the consumer’s ability to manage the PCA program.  (If 
this box is checked, conduct a complete Consumer Assessment to Manage PCA 
Services.)

4th Review

Date of Review Date of most recent Consumer Assessment to Manage PCA Services

Name and Title of Assessor

Check One:  

I have reviewed the most recent Consumer Assessment to Manage PCA Services and 
there have been no changes.

I have reviewed the Consumer Assessment to Manage PCA Services and there have 
been changes that impact the consumer’s ability to manage the PCA program.  (If 
this box is checked, conduct a complete Consumer Assessment to Manage PCA 
Services.)

PCA-RCA-1 (01/07)